(One System per Report) / CTF
8003 / System Certification Given
Frequency / Annual: / Semi-Annual:
Date of Inspection:
Occupancy Information
Occupancy Name: / Occupancy Address:
Building Owner: / Phone Number: / Owner Address:
Contact Person: / Phone Number:
System Information (where applicable)
Size: / UL 300
Yes No / Make:
System Alarmed:
Yes No / Central Station Monitoring: Yes No / Monitoring Company:
Panel Location: / Hood Location:
Testing Agency Information
City of Tacoma Fire Protection License: / Washington State Contractor License:
Testing Agency Name: / Address:
Phone: / E-mail:
Problems Found: (Explain any “no” responses and use the back page if necessary)
Corrections Made:
Date Corrected: Corrected by: (Sign)
This report certifies this fire and life safety system has been properly inspected for reliability to cover the items listed in the report and is consistent with NFPA 96 Standard. All discrepancies are noted and have been reported to the building owner or responsible person for corrective action.
TECH NAME: (Print) / (Sign) / Date:
Building Representative: (Print) / (Sign) / Date:

The items on the checklists below shall be inspected and tested. This list does not constitute all of the required inspecting and testing of the fire and life safety system. Refer to the NFPA Standard 17, 17.A & 96 and the manufacturer’s maintenance specifications for inspecting and testing requirements.

Are all cooking surfaces protected?
Does system have adequate volume and/or nozzle coverage?
Positioning of all nozzles is appropriate?
Nozzle caps in place?
Are all appliances inside of the hood protection area?
System is fully operational with inspection and service tag on system cylinder?
All piping and conduit are immobilized with proper hangers and brackets?
Fuse links replaced? / Number of Links: / Date of new Links:
Tested system operation from terminal link for proper operation?
Tested system operation with manual remote for proper operation?
Tested system operation and proper operation of micro switch? / N/A
System components visible and free from obstructions?
Gas shuts down upon system activation? / N/A
Electric power shuts down upon system activation? / N/A
Cylinder hydro test conducted within last 12 years? Hydro Test date:
Is there chemical in the cylinder?
Pressure gauge present and in operational range?
Weight of CO2 or Nitrogen cartridge: / N/A
Are all tamper seals intact?
Class “K” extinguisher in place and serviced?
Range hood activation signal received at building alarm panel? / N/A
Is system free of visual grease buildup?
If no, is the build up / Light: / Medium: / Heavy:
Currently cleaned by (name of company and technician:
Date of last hood cleaning per NFPA standards?
Previous confidence test company and technician:
Has system been fired or been tampered with?
If yes, explain:
DRAWING OF SYSTEM (Sketch of nozzles and appliances)
Problems Found:
Corrections Made: